Are you good at charting in "real time?"

Are you good at charting/documenting in "real time," that is getting your assessments and vitals charted close to the time you actually do them instead of catching up with charting hours later at the nursing station? Any tips for how to do this successfully without delaying the rest of your care? Are you faster at documenting than all your co-workers, and if so, any tips?

Our hospital is pushing nurses to start documenting closer to real-time because the charting will be linked to patient acuity. I'm curious to see if this is actually humanely possible; looking for examples of nurses who successfully do this.

Sometimes I am and sometimes I am not. It depends on what is going on at that time but my goal is to chart as close to time as possible. It is hard to do when short staffed and getting admission or post OP patients early in the shift. If I have 6 patients and no patient tech, I can guarantee much of the charting will be behind.

I try to do a quick assessment progress note and complete the quicker charting such as fall risk and IV lines leaving the body assessment last. Sometimes i do the reverse.

I'm in the ER so I have to chart in real time because I never know when assignments are going to be switched or when I go on break, etc. I've found that using the computers in the room help, especially with the assessment. I can ask all the questions as I chart. Then I just make sure to write a quick note every time I go in the pt room and I'm all set. I'm sure it's different on the floor, but that's my trick in the ER. If we charted hours later the pt would already be discharged!!

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Mar 6, '14

Joined: Apr '11; Posts: 3,478; Likes: 4,680

I'm still but a student, however I at least get the VS done and charted in as near real-time as possible. Then once I've got a few minutes, I then chart the "faster" items and then the assessment. Somewhere in there, I'll put in an assessment note.

I am not one of those nurses you will see drifting in a few minutes late and dragging their feet getting their work started.
I find that for me, really pushing through the beginning of the shift gets my day of to a good start and I can keep up with the charting better if the first round of charting, assessments and meds are done efficiently.
I like to chart in the patient room if it is quiet and there are no visitors. The nurses station has more distractions.
There is only so far you can take things. Patient care comes first. These days there is a bigger link to reimbursement in computerized charting, so expect a push towards nursing the charting.

I'm in the ER and I try to. I try to do a quick patient rounding, quick charting atleast a little blurb.

Lately with staffing at an all time low and patient volume at an all time high I feel like I can never catch up on my chart. I'm actually DOING stuff, just so busy that charting is my last priority. CYA always prevails though... I try to atleast go back and finialize my charts on very critical patients.

Mar 6, '14

Joined: Aug '05; Posts: 38,991; Likes: 48,075

I the ED it is the nature for real time charting. In other units it is not so easy. I would fail miserably at this. I ALWAYS put off charting until patient care was finished.

I am so NOT into this real time charting. I think it removes the nurses attention away from the patient to the computer.. And they wonder why patients complain.

Mar 6, '14

Joined: Aug '09; Posts: 6,369; Likes: 26,283

I felt the most efficient way to chart was at the bedside. I would enter my assessment as I was performing it. Actually gave me a little more time with the patient and I couldn't forget any details.

I will update the vitals, hourly urine outputs, and document any call I made to anyone including physicians/pharmacy/lab and their responses as close to real time as possible, but that's it. I will do the assessments in real time if I can, but usually they are getting done later in the shift. Patient care comes first.

I also like to enter the skin assessments on our multiple traumas at the bedside, since I don't always trust my memory at 4 a.m....which humerus was ORIF'ed and which still has the ex fixes on? Which wounds are uncovered, and what type of dressings are on the others? Where all do they have lacerations, bruising? What amount of type of drainage do they have from all these wounds? You get the idea.

The full assessment usually gets entered at least 2-3 hrs into my shift; we do NOT chart by exception, and our form is really long. So if I enter it all right at the beginning, my other pt is kept waiting. (I imagine this is much more of an issue on the floors, where they get 6-7 pts on the noc shift.)

Mar 6, '14

Joined: Oct '10; Posts: 2,886; Likes: 8,713

Yes, in the ED, charting in real time is de riguer.

However, when I worked on the floor, I struggled with this, too. I had my own brain sheets where I would make notes of any exceptions, then go into the computer system and chart after I did all of my assessments. Sometimes if things were busy, I wouldn't have time to chart until late into the shift. Sometimes, I would try to be very systematic, going into each room and charting at the bedside, but that had several drawbacks, such as A) Frequent interruptions due to other patients needing things, B) Feeling impersonal, looking at the computer screen instead of interacting with the patient- it just felt awkward, or C) Needing to get out of the room because the patient or visitor wouldn't stop talking to me. I really preferred to find a quiet computer in a corner somewhere where I could concentrate.

I have always made real time charting a priority. As other have said, in the ER it is necessary to do this, as well as it fitting into the flow fairly well.

When I worked on the floor I would do my rounds (assessments, meds, toileting) then immediately sit down and narrative/flow sheet chart on all of my patients (meds were charted bedside). This was my routine every day, the only thing that would interrupt this was a patient in distress (eg. A fall, medical emergency, emotional freak out etc) that required more urgent intervention and charting. I can't recall a single time when I didn't complete my initial charting prior to my break (even the infamous 1st break that had to leave by 8:30).

It was always a part of my time management routine, and I came from the "not charted = not done" school of nursing, so charting was always a priority for me.

I don't know if I have any tips other than to ensure that you are thinking of charting as an important part of safe care and prioritize it as such, rather than thinking of it as a chore you have to complete prior to leaving for the day.

Mar 6, '14

Joined: Aug '07; Posts: 1,025; Likes: 947

I chart temperatures, I/Os, and any drip titrations in real time. New admissions I always chart in the room for my initial assessment so I don't miss anything. Anything else I can chart later after I get my night started. I get all of my baths done asap and all my preparations for the end of my shift done by 2200 so that I can focus on charting and reading progress notes later on. My vitals are imported from the bedside monitors with just a few clicks, so they're easy to save at any time. I always like to chart everything in the same order every time to ensure that I don't forget anything.